|
TO BE COMPLETED ONLY BY CERTIFYING PHYSICIAN TO BE COMPLETED BY CORONER
<br />26.ToM*IH14IOIfR KnOWled Oeath Occurred at the time, date and coca, a 27. On the basis of examination andlor investigation. in my opinion death occurred at the
<br />the Ca
<br />UWS) *!Tr as stated. tons, date and piece, and due to the CaU11011) and manner sill suited
<br />signature 0 S#gnatu_ 000.
<br />7 28. DATE SIGNED (Month. Day. Year) If 29. DATE SIGNED (Month, Day, year)
<br />2-
<br />-NAME.TrTLE AND MAILING ADDRESS OF CERTIFIERlFCORCINER (TypeAtirritt)
<br />3-
<br />Martin U 10 'Z - 155 Clarkson St. Denver.Colorado zIR 80203
<br />31. NAME ATTRAU P &&914 FEN-1:5714 (Typs'Prino
<br />4_ 32 MANNER OF DEATH 33s. DATE OF INJURY 330. TIME OF 33d. DESCRIBE HOW INJURY OCCURRED
<br />dkistum] CI Pending (Month, Day, Visor) INJURY WORK?
<br />1. M 133c. INJURY AT
<br />5- vastigation 0 Yes 0 No
<br />0 Accident
<br />❑ Suckle Manner Undit•ntuntid -
<br />Manner 339. PLACE OF INJURY -At hams, term tactory.othole 33L LOCATION Mossit and Number or Rural Route Number, City. Counly. SINIM
<br />buffillmg. OM (Seedy) • Homicide
<br />34. IMMEDIATE CAUSE (ENTER ONLYONE CAUSE PER LINE FOR lei (61 AND (41 Do not enter !;• - of dying (&g. Cardiac or Respiratory Armet) Interval between onset
<br />PART WW death
<br />_,�ff iriency
<br />ggir
<br />CONDITIONS gu gy Interval bathimen onset
<br />IF ANY WHICH "I disay S
<br />GAVE RISE TO Pneumonia
<br />IMMEDIATE CAUSE (b)
<br />STATING THE 50K TO OR AS A CONS-E-O-U-EN- "EF Interval between onset
<br />death
<br />LAST (c) (c)
<br />UNDERLYING CAUSE Lung carcinoma squamous cell years 3 mo
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related to cause in 35. A BY 36. IF YES worms findings cc d
<br />11 PART I le.9, alcohol abuse, obesity, iy�:O:ivp)
<br />IlTokan. In determining cause of death?
<br />NO
<br />STATE OF 'COLM400. CITE -ANi CONTY OF DENKR
<br />rbereby xmr_tify thii dotument is a true and correct copy of the original Issued in the City
<br />and bounty of Denver. this I O-th -day of FebruarY A.D., 1992.
<br />6r 'Prepared on green basketweave V J)x"Pon, M.D. Local eg s rar
<br />paper imprqsseirwith'the raised seal of the Dept. of
<br />Health A Hospitals.•City & County of Denver, Colo.
<br />MALTY BY LAY, - Section 25-2-118, Colo. Revised Statutes, 1982, if any person Essie J. oln Depuzy xegisrFir-
<br />alters, uses, or attempts to use or furnishes to another for deceptive use or
<br />supplies false information for any vital statistics certificate.
<br />T.nt- Three (3). in Block 22, Nagy's Addition to Grand Island, Hall County, Nebraska and its
<br />M
<br />M
<br />z
<br />C:D
<br />> 0 C::D
<br />M (A C_-
<br />cf)
<br />r\)
<br />Co
<br />r) :C ;;,
<br />r
<br />U)
<br />17TI
<br />C=)
<br />Ul cn 'I
<br />CD
<br />ril
<br />cc
<br />AA
<br />r
<br />CD
<br />c-n
<br />200007644
<br />O
<br />STATE OF COLORADO STATE FILE NUMBER
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS NAME IfirSt. Middle. LeSO 2. SEX 3. DATE OF DEATH (Month. Day. year)
<br />Donald Day WP IMale February 5,1992
<br />4. SOCIAL SECURITY ba AGE • Last I 5b. UNDER I YEAR Sc. -UNDER I 6. DATE OF BIRTH 7. BIRTHPLACE (City and State or Foreign
<br />NUMBER amnasy iyears)
<br />_11AY
<br />me$ : Days M... Ilitonth. Day. year) Country)
<br />446-30-9096 65 Aug. 11, 1926 Mutual, OK.
<br />rMFID-FrEDENT EVER IN W. PLACE OF DEATH (Cheek only one)
<br />U.S. ARMED FORCES?
<br />0 yet =40 HOSPITAL: OTHER
<br />z Inomblint D ER/Outpaperm 0 DOA a Nursing Home 0 Residence D Other ISeecifil
<br />90. FACILITY NAME lit not insutumm give street and number) ft CITY. TOWN, OR LOCATION OF DEATH a& COUNTY OF DEATH
<br />W.h.l. AUPPI TAP
<br />MAtEDIENWI 100. KIND OF BUSINESS/INDUSTRY 11. MARITAL STATUS - MarneC. 12. SPOUSE lit wife, give golden Rants)
<br />(Give kind Of Work done during most of Working lite. Never Married. Widowed.
<br />Do not use milled) Divorced (Specify)
<br />Mine Safety And
<br />Health Specialist U.S. Government Married Eleanor Cable
<br />139. RESIDENCE•STATE 130. COUNTY 13c. CITY. TOWN. OR LOCATION 13d. STREET AND NUMBER
<br />Colorado Jefferson Lakewood 1102 So. Dudley St.
<br />I
<br />13a. INSIDE 11311. ZIP CODE 14. WAS DECEDENT OF HISPANIC ORIGIN? 15, RACE: American Indian, 16. DECEDENTS EDUCATION Opacity only htV;;r6i_
<br />CITY
<br />While. etc.
<br />No or Yea • if yes. specify Cuban, week. (spactly) noted) Esamen" or ".*r "11+)
<br />LIMITS? Pueno Rican. am) %1Rn=Mh 121 (13 thro:g"h M16
<br />0OTr
<br />xvp 80232 R No D Yes White
<br />ONO
<br />I . A M A-NAM (First. Middle. Last) is. MOTHER-NAME FW1 waice"affle)) 19. INFORMANT -NAM E-and rstat-onshm to tleoaaaefl
<br />Hubert D. Rapp Esther Privett lEleanor E. Rapp-Wife
<br />20a. METHOD OF DISPOSITION 200. PLACE OF DISPOSITION (Name of cemetery, crematory. or 20c. LOCATION • CayorTown. State
<br />0 Burial X Cremation 0 F19movel from State other pace)
<br />Colorado Cremation Service Lakewood, Co.
<br />0 Donation 0 Other (specify)
<br />211a. SOMA FU RAL IRECTOR OR PERSON ACTING AS SUCH '214 NAME AND ADDRESS OF FACILITY:
<br />Horan&McConaty Family Blvd. Mortuary
<br />►
<br />3020 Federal Blvd. Denver C0 ZIP., 80211
<br />22AL RE TRUM SIGNATURE 224 DATE FlIf yWpH. ED Y it)
<br />1992
<br />. -, --9A QNOUNUF0 05AD 1 25. WAS CORONER NOTIFIED?
<br />-6727A - (Yes WHO)
<br />Wbr; it,
<br />m I ua ry 6:27ammmr I No
<br />TO BE COMPLETED ONLY BY CERTIFYING PHYSICIAN TO BE COMPLETED BY CORONER
<br />26.ToM*IH14IOIfR KnOWled Oeath Occurred at the time, date and coca, a 27. On the basis of examination andlor investigation. in my opinion death occurred at the
<br />the Ca
<br />UWS) *!Tr as stated. tons, date and piece, and due to the CaU11011) and manner sill suited
<br />signature 0 S#gnatu_ 000.
<br />7 28. DATE SIGNED (Month. Day. Year) If 29. DATE SIGNED (Month, Day, year)
<br />2-
<br />-NAME.TrTLE AND MAILING ADDRESS OF CERTIFIERlFCORCINER (TypeAtirritt)
<br />3-
<br />Martin U 10 'Z - 155 Clarkson St. Denver.Colorado zIR 80203
<br />31. NAME ATTRAU P &&914 FEN-1:5714 (Typs'Prino
<br />4_ 32 MANNER OF DEATH 33s. DATE OF INJURY 330. TIME OF 33d. DESCRIBE HOW INJURY OCCURRED
<br />dkistum] CI Pending (Month, Day, Visor) INJURY WORK?
<br />1. M 133c. INJURY AT
<br />5- vastigation 0 Yes 0 No
<br />0 Accident
<br />❑ Suckle Manner Undit•ntuntid -
<br />Manner 339. PLACE OF INJURY -At hams, term tactory.othole 33L LOCATION Mossit and Number or Rural Route Number, City. Counly. SINIM
<br />buffillmg. OM (Seedy) • Homicide
<br />34. IMMEDIATE CAUSE (ENTER ONLYONE CAUSE PER LINE FOR lei (61 AND (41 Do not enter !;• - of dying (&g. Cardiac or Respiratory Armet) Interval between onset
<br />PART WW death
<br />_,�ff iriency
<br />ggir
<br />CONDITIONS gu gy Interval bathimen onset
<br />IF ANY WHICH "I disay S
<br />GAVE RISE TO Pneumonia
<br />IMMEDIATE CAUSE (b)
<br />STATING THE 50K TO OR AS A CONS-E-O-U-EN- "EF Interval between onset
<br />death
<br />LAST (c) (c)
<br />UNDERLYING CAUSE Lung carcinoma squamous cell years 3 mo
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related to cause in 35. A BY 36. IF YES worms findings cc d
<br />11 PART I le.9, alcohol abuse, obesity, iy�:O:ivp)
<br />IlTokan. In determining cause of death?
<br />NO
<br />STATE OF 'COLM400. CITE -ANi CONTY OF DENKR
<br />rbereby xmr_tify thii dotument is a true and correct copy of the original Issued in the City
<br />and bounty of Denver. this I O-th -day of FebruarY A.D., 1992.
<br />6r 'Prepared on green basketweave V J)x"Pon, M.D. Local eg s rar
<br />paper imprqsseirwith'the raised seal of the Dept. of
<br />Health A Hospitals.•City & County of Denver, Colo.
<br />MALTY BY LAY, - Section 25-2-118, Colo. Revised Statutes, 1982, if any person Essie J. oln Depuzy xegisrFir-
<br />alters, uses, or attempts to use or furnishes to another for deceptive use or
<br />supplies false information for any vital statistics certificate.
<br />T.nt- Three (3). in Block 22, Nagy's Addition to Grand Island, Hall County, Nebraska and its
<br />
|